1427347350 NPI number — AYSAR BENYAMEN FATHALAH-MAMMO,PHYSICIAN,PC

Table of content: (NPI 1427347350)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427347350 NPI number — AYSAR BENYAMEN FATHALAH-MAMMO,PHYSICIAN,PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AYSAR BENYAMEN FATHALAH-MAMMO,PHYSICIAN,PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1427347350
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/31/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
372 ELM DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSLYN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11576-3013
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-801-0662
Provider Business Mailing Address Fax Number:
718-833-1016

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8000 4TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11209-3959
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-748-2818
Provider Business Practice Location Address Fax Number:
718-833-1016
Provider Enumeration Date:
03/31/2011

Additional Information

Authorized Official

Authorized Official Last Name:
FATHALLAH-MAMMO
Authorized Official First Name:
AYSAR
Authorized Official Middle Name:
B
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
516-801-0662

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  212576 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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